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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> ONSITE HAZARDOUS WASTE TREATMENT NOTIFICATION - FACILITY PAGE <br /> Page of L <br /> I. FACILITY IDENTIFICATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID# <br /> II. STATUS <br /> NOTIFICATION STATUS 600. PERMIT STATUS(Check all that apply) 601• <br /> ❑a. Amended a. Facility Permit ❑d. Variance <br /> ❑b. Initial ❑b. Interim Status ❑e. Consent Agreement <br /> ❑c. Renewal(PBR Only) ❑c. Standardized Permit <br /> III. NUMBER OF UNITS AT FACILITY <br /> (Indicate the number of units you operate in each tier. Attach one unit notification page for each unit except CE-CL) <br /> A. Conditionally Exempt—Small Quantity Treatment(CESQT)(May not function under any other tier.) 602. <br /> B. Conditionally Exempt Specified Wastestream(CESW) <br /> C. Conditionally Authorized(CA) C>AIr Glyi,T <br /> D. Permit by Rule(PBR) <br /> E. Conditionally Exempt—Limited(CEL) <br /> F. / Conditionally Exempt Commercial Laundry(CE-CL) (No unit page is required for laundries.) <br /> G. 1 TOTAL UNITS(Must equal the number of unit notification pages attached plus the number of CE-CL units.) <br /> IV. CERTIFICATION AND SIGNATURE <br /> Waste Minimization-I certify that I have a program in place to reduce the volume,quantity and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment. <br /> Tiered Permitting Certification- I certify that the unit or units described in these documents meet the eligibility and operating requirements of state statutes and <br /> regulations for the indicated permitting tier,including generator and secondary containment requirements. I certify under penalty of law that this document and all <br /> attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the <br /> information submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the <br /> information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> I am aware that there are substantial penalties for submitting false information,including the possibility of fines and imprisonment for knowing violations. <br /> SIGNATURE�MWNER/OPERAT R DATE 603. <br /> 7 //- j° - -,2'7 <br /> NAME OF OWNER/OPERATOR 604. TITLE OF OWNER/OPERATOR 605. <br /> -3)V K&- -4-a- P�'EswIZ�70- <br /> REQUEST FOR SHORTENED REVIEW PERIOD(CE and CA only) ❑ Yes ❑ No <br /> State Reason for Request: <br /> V.ATTACHMENTS(Check if attached) <br /> ALL tiers except CE-CL(Laundries)must submit: PBR ONLY <br /> ® 1. One unit specific notification page and one treatment process page per unit ❑1. Tank and container certifications,if required <br /> ❑2. Plot Plan(or other grid/map) ❑2. Notification of local agency or agencies <br /> C]3. Notification of property owner,if different from business owner <br /> PBR&CA ONLY: <br /> ❑1. Closure Financial Assurance(formerly DTSC form 1232) <br /> M Self Certified(<$10,000) ❑ Other mechanism <br /> C]2. Prior Enforcement History,if applicable <br /> UPCF hwfl772f(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />